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Case Study: BP Texas City Explosion 23 March 2005

Beginning in 2002, BP Group and Texas City managers received numerous warning signals about a possible major catastrophe at Texas City. In particular, managers received warnings about serious deficiencies regarding the mechanical integrity of aging equipment, process safety, and the negative safety impacts of budget cuts and production pressures.  Financial and personal safety metrics largely drove BP Group and Texas City performance, to the point that BP managers increased performance site bonuses even in the face of the three fatalities in 2004. Except for the 1,000 day goals, site business contracts, manager performance contracts, and VPP bonus metrics were unchanged as a result of the 2004 fatalities.

While the Texas City site’s training department’s budget and process safety staff were being cut beginning in 1999, corporate BP identified a gap in training at the refinery. A 2003 external audit found that “[t]raining in most areas is not up to the challenge of performance expectations and anticipated turnover.”

Eight serious ISOM blowdown drum incidents occurred from 1994 to 2004; in two, fires occurred. In six, the blowdown system released flammable hydrocarbon vapors that resulted in a vapor cloud at or near ground level that could have resulted in explosions and fires if the vapor cloud had found a source of ignition. These incidents were early warnings of the serious hazards of the ISOM and other blowdown systems’ design and operational problems. The incidents were not effectively reported or investigated by BP or earlier by Amoco. Only three of the incidents involving the ISOM blowdown drum were investigated.

BP’s problems with its incident investigation system were not isolated to the ISOM unit. In the two years before the incident, refinery audits and other reviews indicated larger problems with the Texas City incident investigation system. A 2003 external audit found that “a coordinated, self-monitoring and self-assessment process is not evident throughout the line organization.” A 2004 audit graded as “poor” how incident investigation information was analyzed to monitor trends and develop prevention programs.

The refinery required that a MOC be initiated for any change that involved process chemicals, process/equipment technology, equipment piping, process control and instrumentation, operating procedures, safe operating limits, relief/safety systems, personnel/staffing/organization/outsourcing, and occupied buildings.  Organizational changes that could adversely impact process safety, such as changes in the management structure, budget cuts, etc., generally were not evaluated.

A review of compliance audits at the Texas City refinery revealed that many of the process safety system deficiencies causal to the ISOM incident had been previously identified by BP auditors.

The Hazards of Unit Startup

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